Why Cerebral Visual Impairment Is Missed — and Why Early Screening Matters

Research By: Karen L. Harpster, PhD, OTR/L | Melissa L. Rice, OD | Terry L. Schwartz, MD

Post Date: May 13, 2026 | Publish Date:

Caregiver questionnaires can help identify cerebral visual impairment earlier, especially for children at higher medical risk.

Cerebral visual impairment (CVI) is now recognized as the leading cause of childhood bilateral low vision in developed countries. Despite this, it is often missed or diagnosed much later than it should be.

New research from Cincinnati Children’s highlights both the scale of this problem and a clear opportunity to improve care. Across three related studies, researchers found that CVI can be identified much earlier than it is today — especially when caregiver completed screening questionnaires are used consistently and early.

“Early detection is incredibly important,” says Karen Harpster, PhD, OTR/L, an occupational therapist and clinician researcher in the Division of Occupational Therapy and Physical Therapy. “When CVI is identified early, children can receive vision‑specific interventions at a time when their brains are rapidly developing.”

Why CVI Is Often Missed

Unlike vision disorders linked to the structure of the eye, CVI affects how the brain processes visual information. A child’s eyes may be healthy, but the brain has difficulty making sense of what the eyes see.

Because of this, standard eye exams may appear normal. At the same time, children with CVI may struggle in ways that are not always recognized as vision-related. These children may have trouble recognizing faces or objects, avoid busy visual environments, rely more on touch or hearing or tire quickly during visually demanding tasks.

CVI can affect children in different ways. Some children have mild, hard-to-notice difficulties while others cope with significant challenges. Symptoms also can change from day to day depending on their visual environment or level of fatigue, which makes CVI harder to detect during short clinical visits.

As a result, CVI can be mistaken for developmental delay, attention-related concerns or behavioral concerns rather than a vision condition.

The Hidden Consequence of Late Diagnosis

One of the studies, published in Ophthalmic and Physiological Optics in September, 2025, reviewed more than a decade of medical records and found that children with CVI are diagnosed around 4.5 years of age. In many cases, signs of CVI were present much earlier. Some children waited nearly 10 years after their first eye exam to receive a formal diagnosis.

Children with milder symptoms were more likely to be missed. These children often required multiple visits before clinicians recognized that visual processing — not eyesight — was the underlying issue.

This delay has real consequences. Early childhood is a period when the brain is especially responsive to intervention. When CVI is identified early, targeted strategies can support visual attention, communication, movement, object recognition and participation in everyday activities.

“When CVI isn’t identified early, children miss critical opportunities for support during a time when the brain is most responsive to intervention,” says Melissa Rice, OD, a pediatric optometrist in the Division of Ophthalmology. “Those early years matter.”

The studies also found that many children with known CVI risk factors — including prematurity, seizures, genetic conditions, brain injury, hypoxic-ischemic events or structural differences in the brain — went years without any targeted vision evaluation. These children are among those most likely to benefit from early identification.

Caregiver Questionnaires: A Practical Path to Earlier Detection

Two of the studies focused on caregiver completed questionnaires designed to identify visual behaviors linked to CVI. These tools do not measure visual acuity. Instead, they capture what caregivers observe in daily life, such as how a child looks at people and objects, tracks movement, reaches for items or responds in visually complex environments.

For infants and toddlers, the Preverbal Visual Assessment, evaluated in a study published in Developmental Medicine and Child Neurology in October, 2025, showed strong potential. In children under age 2 — including preverbal infants — the tool demonstrated high sensitivity across several areas of visual function. When caregivers reported concerns in visual attention, communication, visual-motor coordination or visual processing, the likelihood of CVI was significantly higher. The tool was especially effective during the first year of life, when traditional vision testing options are limited.

For older children, the Teach CVI screening tool, assessed in a study published in Research in Developmental Disabilities in November, 2025, offered complementary strengths. With versions tailored to age and motor ability, Teach CVI showed moderate to strong accuracy when used alongside medical history and clinician observation. Researchers also found that a shorter set of screening questions performed nearly as well as the full questionnaire, making it more practical for busy clinical settings.

Together, these tools provide screening options from infancy through early adolescence. They capture functional visual behaviors that are not assessed through standard eye exams.

A Unified Call to Action

Across all three studies, a shared roadmap emerged:

Screen early, especially for children with known medical risk factors.

Use validated caregiver questionnaires as an initial screening step.

Increase awareness of CVI among pediatricians, neurologists, therapists and eye care providers.

Integrate screening tools into routine clinical workflows using electronic prompts and automated scoring.

Pay closer attention to mild and moderate CVI, which are most likely to be overlooked.

The findings show that CVI does not need to remain undetected until preschool or later. With systematic screening, caregiver input, and provider education, earlier identification is achievable in real-world clinical settings.

“When CVI is recognized earlier, children gain access to specialized support that helps them learn, move, communicate and participate more fully in their daily lives,” Terry Schwartz, MD, a pediatric ophthalmologist in the Division of Pediatric Ophthalmology says.

About the Studies

The findings described here come from three related studies led by Karen Harpster, PhD, OTR/L, Melissa Rice, OD, and Terry Schwartz, MD, of the Division of Occupational Therapy and Physical Therapy and the Division of Ophthalmology. First authors varied across the studies and included Elsie Bush from the Division of Occupational Therapy and Physical Therapy. Co-authors also included members of the Division of Pediatric Ophthalmology and the Division of Patient Services Research.